Definition

An electrophysiology (EP) study of the heart is a nonsurgical analysis of the electrical conduction system (normal or abnormal) of the heart. The test employs cardiac catheters and sophisticated computers to generate electrocardiogram (EKG) tracings and electrical measurements with exquisite precision from within the heart chambers.

The EP study can be performed solely for diagnostic purposes. It also is performed to pinpoint the exact location of electrical signals (cardiac mapping) in conjunction with a therapeutic procedure called catheter ablation.

The test is simple, not painful, and performed in a special laboratory under controlled clinical circumstances by cardiologists and nurses who subspecialize in electrophysiology.

  Purpose

A cardiologist may recommend an EP study when the standard EKG, Holter monitor, event recorder, stress test, echocardiogram, or angiogram cannot provide enough information to evaluate an abnormal heart rhythm, called an arrhythmia.

An EP study also may be beneficial in diagnosing a suspected arrhythmia in a patient who shows symptoms of an arrhythmia but in whom it could not be detected from other tests.

The purpose and great value of an EP study is that it offers more detailed information to the doctor about the electrical activity in the heart than the aforementioned noninvasive tests because electrodes are placed directly on heart tissue. This allows the electrophysiologist to determine the specific location of an arrhythmia and, oftentimes, correct it during the same procedure. This corrective treatment is permanent and considered a cure, and, in many cases, the patient may not need to take heart medications.

EP studies may be helpful in assessing:

• certain tachycardias or bradycardias of unknown cause.
• patients who have been resuscitated after experiencing sudden cardiac death.
• various symptoms of unknown cause, such as chest pain, shortness of breath, fatigue, or syncope (dizziness/fainting).
• response to anti-arrhythmic therapy.

  Precautions

Pregnant patients should not undergo an EP study because of exposure to radiation during the study, which may be harmful to the growing baby.

Patients who have coronary artery disease may need to have that treated before having an EP study.

  Description

The rhythmic pumping action of the heart, which is essentially a muscle, is the result of electrical impulses traveling throughout the walls of the four heart chambers. These impulses originate in the sinoatrial (SA) node, which are specialized cells situated in the top right chamber of the heart: the right atrium. Normally, the SA node, acting like a spark plug, spontaneously generates the impulses, which travel through specific pathways throughout the atria to the atrioventricular (AV) node. The AV node is a relay station, sending the impulses to more specialized muscle fibers throughout the bottom chambers of the heart: the ventricles. If these pathways become damaged or blocked or if extra (abnormal) pathways exist, the heart's rhythm may be altered (perhaps too slow, too fast, or irregular), which can seriously affect the heart's pumping ability.

The patient is transported to the x-ray table in the EP lab and connected to various monitors. Sterile sheets are placed over him or her. A minimum of two catheters are inserted into the right femoral (thigh) vein in the groin area. Depending on the type of arrhythmia, the number of catheters used in an EP test and their route to the heart may vary. For certain tachycardias, two more catheters may be inserted in the left groin and one in the internal jugular (neck) vein or in the subclavian (below the clavicle) vein. The catheters are about 0.08 in (2 mm) in diameter, about the size of a spaghetti noodle. The catheters used in catheter ablation are slightly larger.

With the help of fluoroscopy (x rays on a television screen), all the catheters are guided to several specific locations in the heart. Typically, four to 10 electrodes are located on the end of the catheters, which have the ability to send electrical signals to stimulate the heart (called pacing) and to receive electrical signals from the heart--but not at the same time (just as a walkie-talkie cannot send and receive messages at the same time).

First, the electrodes are positioned to receive signals from inside the heart chambers. This allows the doctor to measure how fast the electrical impulses travel currently in the patient's heart. These measurements are called the patient's baseline measurements. Next, the electrodes are positioned to pace: The EP team actually tries to induce (sometimes in combination with various heart drugs) the arrhythmia that the patient has previously experienced so the team can observe it in a controlled environment, compare it to the patient's clinical or spontaneous arrhythmia, and decide how to treat it.

Once the arrhythmia is induced and the team determines it can be treated with catheter ablation, cardiac mapping is performed to locate precisely the origin and route of the abnormal pathway. When this is accomplished, the ablating electrode catheter is positioned directly against the abnormal pathway, and high radio-frequency energy is delivered through the electrode to destroy (burn) the tissue in this area.

  Preparation

The following preparations are made for an EP study:

• the patient may be advised to stop taking certain medications, especially heart drugs, that may interfere with the test results.
• blood tests usually are ordered the week before the test.
• the patient undergoes conscious sedation (awake but relaxed) during the test. This is accomplished quite often with the anesthetic drugs VersedR (Roche laboratories) and fentanyl.
• a local anesthetic is injected at the site of catheter insertion.

  Aftercare

The patient needs to rest flat in bed for several hours after the procedure to allow healing at the catheter insertion sites.

The patient often returns home either the same day of the test or the next day. Someone should drive him or her home.

The doctor may prescribe drugs and/or insert an AFCD to treat the arrhythmia and may do a possible follow-up EP study.

  Risks

The EP diagnostic study and catheter ablation are low-risk procedures. There is a small risk of bleeding and/or infection at the site of catheter insertion, but this occurs less than 1% of the time. Blood clot formation occurs only two in 1,000 instances and is minimized with blood thinner medications administered during the procedure. Vascular injuries causing hemorrhage or thrombophlebitis are possible but occur less than 0.7% of the time. Cardiac perforations occur only in one or two per 1,000 instances. If the right internal jugular vein is accessed, the small possibility of puncturing the lung with the catheter exists, which, at worst, could cause a collapsed lung.

Because ventricular tachycardia or fibrillation (lethal arrhythmias) may be induced in the patient, the EP lab personnel must be prepared to defibrillate the patient as necessary.

Normal results

The heart initiates and conducts electrical impulses normally.

Abnormal results

Confirmation of arrhythmias, such as:

• supraventricular tachycardias
• ventricular arrhythmias
• accessory (extra) pathways
• bradycardias

   Key Terms:

Ablation Remove or destroy, such as by burning or cutting. Angiogram X ray of a blood vessel after special x-ray dye has been injected into it. Bradycardia Slow heartbeat. Cardiac catheter Long, thin, flexible tube that is threaded into the heart through a blood vessel. Cardiologist Doctor who specializes in diagnosing and treating heart diseases. Echocardiogram Ultrasound image of the heart. Electrocardiogram Tracing of the electrical activity of the heart. Electrode Medium for conducting an electrical current--in this case, platinum wires. Electrophysiology Study of how electrical signals in the body relate to physiologic function. Event recorder A small machine, worn by a patient usually for several days or weeks, that is activated by the patient to record his or her EKG when a symptom is detected. Fibrillation Rapid, random contraction (quivering). Holter monitor A small machine, worn by a patient usually for 24 hours, that continuously records the patient's EKG during usual daily activity. Stress test Recording a patient's EKG during exercise. Supraventricular tachycardia A fast heart beat that originates above the ventricles. Tachycardia Fast heartbeat. Vascular Pertaining to blood vessels.

   Resources:

Books

• Grubb, Blair P., and Brian Olshansky. Syncope: Mechanisms and Management. Armonk, NY: Futura Publishing, 1997.
• Horovitz, Emmanuel. Heartbeat: A Complete Guide to Understanding and Preventing Heart Disease. Los Angeles: Health Trend Publishing, 1988.
• Singer, Igor. Interventional Electrophysiology. Baltimore: Williams & Wilkins, 1997.

Organizations

• Cardiac Arrhythmia Research and Education Foundation (C.A.R.E.). 2082 Michelson Dr. #301 Irvine, CA 92612 1-800-404-9500. http://www.longqt.com>
• Medtronics Manufacturer of Therapeutic Devices. 710 Medtronic Parkway NE, Minneapolis, MN 55432-5604. (800) 328-2518. http://www.medtronic.com
• Midwest Heart Specialists. Physician Office Building, 3825 Highland Ave., Tower 2, Ste. 400, Downers Grove, Illinois 60515. (630) 719-4799. http://www.midwestheart.com
• United States Catheter Instruments (USCI). 129 Concord Road Billerica, MA 01821. (800) 826-2273.